Things We Can Do To Better Meet The
Needs Of Our Hearing Impaired Patients
Robert W. Sweetow, Ph.D.
University of California, San Francisco
The brain must……
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Detect
Discriminate
Localize
Segregate auditory figure from ground
Perceptually learn new as well as familiar auditory
dimensions
• Recognize and identify the source
Phillips, 2002
Problems for older listeners
• No problem in ideal listening conditions
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Quiet
One talker
Familiar person
Familiar topic, situation
Simple task, focused activity
• Difficulty in non-ideal listening conditions
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Noise
Multiple talkers
Strangers
New topic, situation
Complex task, many concurrent activities
Fast pace
Perceptual and cognitive declines (resource
limitations) in elderly
• Speed of processing
• Working memory
• Attentional difficulties (noise,
distraction and executive control)
Wingfield and Tun, 2001Seminars in Hearing
Threshold elevation can account for nearly all
of the changes in speech perception with age
(in quiet or in less demanding listening
environments.)
Humes 1996
In complex perceptual tasks, older listeners
are more likely to demonstrate suprathreshold deficits in addition to the effects of
reduced audibility. It is less certain exactly
what factors contribute to these deficits.
Pichora-Fuller & Souza 2003
Impact of aging on speech perception
• Even in the absence of hearing loss, older
subjects require 3-5 dB higher SNR than young
listeners (Schneider, Daneman and Murphy,
2005).
• Older subjects with normal hearing perform
approximately the same as young hearing
impaired subjects (Wingfield and Tun, 2001)
Disadvantage of elderly in SNR for difficult sentence material
(PL = Predictability low; PH = Predictability high)
Frisina and Frisina, 1997
Critical Bandwidth increases with Aging
(lack of lateral inhibition)
Sommers and Gehr, 1997
Brainstem changes
• In noise, brainstem and midbrain blood flow
increases to a greater degree in young
listeners than in older listeners
• Gamma aminobutyric (GABA) diminishes in
older (animals)
Binaural interference
“Difficulty with bilateral amplification
in some elderly patients might be attributable
to “age-related progressive atrophy and/or
demyelination of corpus callosal fibers,
resulting in delay or other loss of the efficiency
of interhemispheric transfer of auditory
information.”
Chmiel et al (1997)
Age-related Hearing Loss
It is likely that peripheral, age-related changes result in a
partial deafferentation of the central auditory processor.
This result in a series of plastic/pathologic compensatory
changes including a down-regulation of inhibitory function
(Caspary et al., 1990, 2008; Eggermont and Roberts, 2004; Sörös et
al.,2009).
The change in inhibitory function, at the level of A1, has a
negative impact on the processing of simple and complex
stimuli in the elderly.
Cortical network effects in Aging
“Consistent with the decline-compensation hypothesis, we found
reduced activation in auditory regions in older compared to younger
subjects, while increased activation in frontal and posterior parietal
working memory and attention network was found. Increased
activation in these frontal and posterior parietal regions were
positively correlated with behavioral performance in older subjects,
suggesting their compensatory role in aiding older subjects to
achieve accurate spoken word processing in noise.”
Wong et al. 2009; Neuropsychologica
Young brain activity is more lateralized
Old brain activity is more distributed
Listening, Comprehending, Communicating
• Stress during auditory processing draws
mental resources away from higher levels of
processing
• Making listening easier by improving input will
have secondary benefits to higher level
processing
Possible cognitive factors in aging
Knowledge is preserved and context is helpful
but there are problems with …..
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Slowing
Working memory
Attention (inhibition of distracters)
Less automatic processing
More trouble coordinating sources of information
All are cognitive consequences if sensory
(or motor) abilities are reduced.
Hypothetical Interaction
• Poor hearing but good memory = 25% loss
• Poor memory but good hearing = 25% loss
• Resultant loss could be only 50% but usually is
more because the impaired memory needs
full sensory input (hearing) in order to only
create a 25% loss and the poor hearing creates
a 25% loss only if the memory is good enough
to help fill in the gaps
Five Things We Can Do to Better Meet the Hearing
Needs of Older People - Overview
• 1) Develop a better clinical testing protocol to define
the elderly patient’s global communication needs
• 2) Match technology to the needs (and abilities) of
the patient
• 3) Integrate the patient’s social support structure
into rehabilitation
• 4) Extend rehabilitation beyond hearing aids
• 5) Employ effective methods to enhance compliance
1. Develop a better clinical testing protocol to define the
elderly patient’s global communication needs
What constitutes a “typical” hearing aid
evaluation?
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Pure tone audio
Monosyllabic speech testing in quiet
Informational counseling
Sometimes…LDLs, MCLs, and RECDs, sentence
recognition in noise
• Perhaps other diagnostic tests such as OAEs
Elements of Communication
(Kiessling, et al, 2003; Sweetow and Henderson-Sabes, 2004)
Potential impediments to achieving mastery of these elements
• Hearing loss
• Neural plasticity and progressive
neurodegeneration
• Global cognitive decline
• Maladaptive compensatory behaviors
• Loss of confidence
Are we really testing
communication?
Current speech perception tests….
• Don’t take the contextual nature of
conversation into account
• Don’t take the interactive nature of
conversation into account
• Don’t allow access to conversational repair
strategies that occur in real life
Flynn, 2003
The biggest mistake we currently make
may be…
• Making hearing aids the focus of our
attention, when the focus should
be…
• Enhancing communication
How to do it?
• All patients should be told at the outset of the
appointment (even during the scheduling) that
they will be receiving:
– a communication needs assessment (CNA)
and
– an overall individualized communication
enhancement plan that will consist of…
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Education and counseling
communication strategies
hearing aids and / or ALDs
individualized auditory training
group therapy
Relevant domains for assessment
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Communication expectations and needs
Sentence recognition in noise
Tolerance of noise
Ability to handle rapid speech
Binaural integration (interference)
Cognitive skills (working memory, speed of processing,
executive function)
Auditory scene analysis
Perceived handicap
Confidence / self-efficacy
Vision
Dexterity
Communication Needs Assessment
Measures beyond the audiogram that can be used to define residual auditory
function.
Objective procedures
• QuickSIN
• BKB-SIN
• Hearing in Noise Test (HINT)
• Listening in Spatialized Noise Sentences (LiSN-S)
• Acceptable Noise Levels (ANL)
• Binaural interference
• Dichotic testing
• Listening span (Letter Number Sequencing)
• TEN
• Rapid (compressed) speech test
• Speechreading
• Dual-tasking
• Need for screening measures
Communication Needs Assessment
Measures beyond the audiogram that can be used to define
residual auditory function.
Subjective measures
• Hearing Handicap Inventory for the Elderly – Screening HHIE-S
• Communication Scale for Older Adults (CSOA)
• Communication Confidence Profile or Listening Self Efficacy
Questionnaire
• Communication partner subjective scales (SAC and SOAC)
Combined (objective and subjective) methods
• Performance Perceptual Test (PPT)
Communication Confidence Profile
Please circle the number that corresponds most closely with
your response for each answer.
If you wear hearing aids, please answer the way that you
hear WITH your hearing aids.
Sweetow, R and Sabes J. Hearing Journal:
(2010); 63:12 ;17-18,20,22,24.
1. Are you confident you can understand conversations when you are
talking with one or two people in your own home?
2. Are you confident in your ability to understand when you are
conversing with friends in a noisy environment, like a restaurant?
3. In order to hear better, how likely are you to do things like moving
closer to the person speaking to you, changing positions, moving to a
quieter area, finding better lighting, etc?
4. If you are having trouble understanding, how likely are you to ask a
person you are speaking with to alter his or her speech by slowing
down, repeating, or rephrasing?
5. How sure are you that you are able to tell where sounds are coming
from (for example, if more than one person is talking, can you identify
the location of the person speaking?)
6. Are you confident that you are able to follow quickly-paced
conversational material?
7. Are you confident that you can focus on a conversation when other
distractions are present?
8. Are you confident that you can understand a person speaking in large
rooms like an auditorium or house of worship?
9. In a quiet room, are you secure in your ability to understand people
with whom you are not familiar?
10. In a noisy environment, are you confident in your ability to
understand people speaking with whom you are not familiar?
11. Are you confident that you can switch your attention back and forth
between different talkers or sounds?
12. If you are having difficulty understanding a person talking, how likely
are you to continue to stay engaged in the conversation?
CCP interpretation
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50+ = Confident
40-50 = Cautiously certain
30-39 = Tentative
Below 29 = Insecure
2. Match technology to the needs
(and strengths) of the patient
• Measure state of readiness
“How important is it for you to improve your
hearing right now?”
• Identify vital factors necessary to achieve success
including dexterity
• Don’t oversell; cost of hearing aids
• Use appropriate features
– Automatic (not manual telecoil)
– Datalogging (allow for nap time)
– Avoid multiple programs, including mute
Hearing aid patients by age
70
60
50
40
%
30
20
10
0
65+
45-65
30-44
18-29
<18
Age (years)
From Strom, Hearing Review, 2001
Requirements for trying amplification
• Problems need to be solved
• Emotional needs to be
addressed
Assessing Motivation
• Source : internal vs. external
• Level:
handicap perception
• desire to rehabilitate
• Don’t fit an unmotivated patient
Tools to get there
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Help patients tell their stories
Clarify the problems
Help patients challenge themselves
Set goals
Develop a plan
Implement the plan
Conduct ongoing evaluations
Egan, 1998
Returns and exchanges average as high as 20% for hearing
aids…….Blaming failure on a single factor is too simplistic
Failure is a product of:
• inaudibility
• poor benefit/cost ratio
• unrealistic expectations and inadequate
counseling
• neural plasticity
• cognitive changes
• poor listening habits
What hearing aids don’t do
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resolve impaired frequency resolution
rectify impaired temporal processing
undo maladaptive listening strategies
Provide proper localization cues*
“properly” reverse neural plastic effects
correct for changes in cognitive function
meet “unrealistic” expectations
Probe Microphone Measures
• Still relevant?
• Issues with open fit hearing aids
• Counseling implications
Do prescriptive formulas work for older
people?
• Testing without aid of visual cues
• Vision testing
Client Oriented Scale of Improvement
COSI
• Self-report questionnaire requiring patient to
list 5 listening situations in which help with
hearing is required. Post-rehab, the reduction
in disability and the resulting ability to
communicate in these situations is quantified.
• Takes less than 5 minutes of patient time, 2
minutes professional time for interpretation
Expectations vs. Goals
• Expectations has a product orientation
– Patient assumes passive role
– Whatever goes wrong is the professional’s
fault
• Goals has a rehabilitation orientation
– Patient assumes active role
– Patient shares in the process
Characteristics of Amplification Tool COAT
• 9-item measure of non-audiologic information
to determine if technology is required.
• Takes 3 minutes of patient time, 2 minutes
professional time for interpretation
Characteristics of Amplification Tool
(COAT)
Newman and Sandridge
• Assesses
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Motivation
Expectations
Preferences
Cosmetics
Cost considerations
http://www.audiologyonline.com/management/uploads/articles/sandridge_COAT.doc
Look at the pictures of the hearing aids. Please place an X on the picture or pictures
of the style you would NOT be willing to use. Your audiologist will discuss with you if
your choices are appropriate for you - – given your hearing loss and physical shape of
your ear.
Mini
BTE
How will your patient (and you) assess outcome?
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Hearing soft sounds
Louder perception
Understanding speech in noise
Listening effort (elevators don’t make travel from
floor 1 to floor 20 more effective, but they do make it
easier) !!!!! (Irv Hafter)
End of day fatigue
Use of new strategies
Quality of life
Benefit or satisfaction
RFC
3. Integrate the patient’s social support structure into
rehabilitation
• Identify communication partners and insist on
their collaboration (including discussion of
communication strategies and home
acoustics)
• Senior outreach programs
• Group therapy
• Recognize need for outside referrals
Perspective of an older adult
who lives with hearing loss
• “When you are hard of hearing you struggle to
hear;
• When you struggle to hear you get tired;
• When you get tired you get frustrated;
• When you get frustrated you get bored;
• When you get bored you quit.
4. Extend rehabilitation beyond hearing aids
• Group therapy
• Individual therapy
Definition of an auditory processing disorder
Jerger and Musiek, 2000
• An auditory processing disorder is a deficit in
the processing of information in the auditory
modality. It may be related to difficulty in
listening, speech understanding, language
development, and learning. These problems
can be exacerbated in unfavorable acoustic
environments.
• What does a peripheral disorder do?????
Does peripheral hearing loss lead to central
auditory dysfunction
If so, can anything be done to
compensate?
So why should AT be expected to produce
benefit?
• Acuity and sensitivity are lower level functions
• Higher level functions (i.e. speech in noise)
require more complex (hierarchical)
processing (such as hemifields and temporal
analysis) that may utilize multiple channels of
perceptual processing not governed by critical
bands
What happened to Aural Rehabilitation?
• declined because outcome measures
concentrated on auditory training and
speechreading and didn’t consider emotional
and psychological by-products
• boring?
• too speech pathology like?
• too time consuming?
• lack of reimbursement
Aural (auditory, audiologic) rehab……
Should NOT be considered an add-on!
Incorporate it at the very beginning
Repair Strategies (synthetic)
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Repeat all or part of message
Rephrase message
Elaborate message
Simplify the message
Indicate the topic of conversation
Confirm the message
Write the message
Fingerspell the message
Nonspecific repairs:
– What? Huh? Pardon?
» Tye-Murray 1998
Group AR
• Active communication education program
(Hickson, 2007)
• Learning to Hear Again (Wayner and Abrahamson,
1996).
• Mayo Clinic program (Hawkins, 2004)
LACE
(Listening and Communication Enhancement)
• Cognitive
– Auditory Working Memory
– Speed of Processing
• Degraded and competing speech
– Background noise
– Compressed speech
– Competing speaker
• Context / Linguistics
• Interactive communication
All of the above are designed to enhance listening and
communication skills and improve confidence levels
Difference in Average CS Score
1st to 4th Quarter
Difference in Average S/B Score
1st to 4th Quarter
(dB SNR)
(dB SNR)
0
-5
-10
10
10
5
5
0
0
(dB SNR)
5
Difference in Average TC Score
1st to 4th Quarter
-5
-10
-15
10
20
30
40
50
60
-30
0
70
10
20
30
40
50
60
70
Subject
Subject
Difference in Average TW Score
1st to 4th Quarter
Difference
DifferenceininAverage
Average TW
MW
MWScore
Score 1st
– 1sttoto4th
4th Quarter
quarter
3
1
2
0
(dB SNR)
(dB SNR)
-25
-25
0
1
0
-1
-2
-4
-2
0
10
20
30
40
Subject
50
60
70
0
10
20
30
40
Subject
0
10
20
30
40
Subject
-3
-1
-15
-20
-20
-15
-5
-10
50
60
70
50
60
70
Why do individuals with similar losses differ so
much?
• Subtle reorganization could produce diverse
presentations by scattering the deficit in
neural space
• Individuals’ brains differ (i.e. variations in
fissural patterns and propensities for
adaptation and recovery)
Why audiologists don’t recommend
comprehensive aural rehabilitation
• Belief that hearing aids alone are adequate
• Lack of belief in outcome measures
• Belief that additional resources (time, money) are
required
• Lack of reimbursement
• Reluctance to ask patients to spend more time or
money
• Inertia
• Laziness
The biggest unresolved questions
• Will audiologists recommend it?
– Impact on return for credit rate?
• Will patients do it?
– Cost of effort
– They do for physical therapy
• Why?
– MD recommendation
– Immediate modeling of therapy after surgery
5. Employ effective methods to enhance
compliance
Reasons patients don’t comply
• Denial of the problem
• The cost (money, time, risk of failure) of the
treatment
• The difficulty of the regimen
• The unpleasant outcomes or side-effects of the
treatment
• Lack of trust in the professional
• Apathy
• Previous negative experience
More reasons
• Symptoms improve before treatment is
finished
• Life-style changes are too hard to make
• Work and family demands interfere with
following the therapy correctly
• Patients come to identify the treatment with
their illness
Suggestions
• Compliance generally increases if patients are
given clear and understandable information
about their condition and progress in a sincere
and responsive way
• Simplify instructions and treatment regimen
as much as possible.
• Have systems in place to generate treatment
and appointment reminders
LACE CE and Compliance
Percent of patients uploading at least 10 sessions
(%)
50
40
*
Patients training at home may
choose not to upload data
30
20
10
0
In Clinic
At Home
Where Patient Completed Session 1
Thanks for Listening